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Guiding Questions:
Introduction to the ARC
Framework and the construct of
Developmental Trauma
Margaret E. Blaustein, Ph.D.
Director of Training and Education
The Trauma Center at JRI
Brookline, MA USA
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Question 1: How do you treat youth
who have experienced trauma?
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Question 2: How do we define
“trauma”?
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Question 3: What is it that we are
treating?
Curriculum - Blaustein
Understanding Trauma in
Childhood
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Traumatic experiences are those that are overwhelming,
invoke intense negative affect, and involve some degree
of loss of control and/or vulnerability. The experience
of trauma is subjective and developmentally bound.
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Multi-layered nature of chronic childhood trauma:
What is “trauma”?
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Overt harm (i.e., physical/sexual abuse)
Lack of need fulfillment (i.e., neglect)
Interpersonal context (i.e., betrayal of caregiving expectations; loss,
abandonment; working models of self and other)
Influence on developmental pathways
Curriculum - Blaustein
Multiple Layers Lead to Complex
Outcomes
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Expectations of harm (from the world and from others)
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Difficulty forming relationships
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Difficulty managing, understanding, and regulating physiology,
feelings and behavior
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Damaged sense of self/fragmented sense of self
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Developmental challenges (problem-solving, agency,
imagination, academic performance, etc.)
Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005
The Trouble with Thinking
Diagnostically
Curriculum - Blaustein
Margaret E. Blaustein, Ph.D The Trauma Center at JRI, Brookline, MA, USA
International Congress, Child Abuse and Neglect November 8-9, 2012
1
Trauma is Complex:
Dimensions of Traumatic Experience
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Type of exposure
Age/developmental stage during exposure
Origin of exposure
Public versus private
Chronicity
Lasting impact
Social support
Contextual issues (culture, family, community)
Presence/absence of additional resources
Presence/absence of additional vulnerabilities
Individual differences (cultural factors, coping style, cognitive,
temperament)
Trauma Diagnoses:
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PTSD
?
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Curriculum - Blaustein
Curriculum - Blaustein
Prevalence of Psychiatric Disorders
in Abused Children (Ackerman et al., 1998)
Does PTSD capture the “face” of
trauma?
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Generalized Anxiety Disorder……….59%
Oppositional Defiant Disorder……….36%
Simple Phobia…………………………36%
Posttraumatic Stress Disorder……….34%
ADHD…………………………………..29%
Conduct Disorder……………………..21%
Dysthymia……………………………..19%
Curriculum - Blaustein
Curriculum - Blaustein
DSM-IV Field Trial for PTSD
Comorbidity in PTSD
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88.3% of men with PTSD met lifetime criteria
for 1 or more other Axis I disorders (National
Comorbidity Study; Kessler)
79% of women with PTSD met criteria for 1+
80% of individuals with PTSD meet criteria for
another psychiatric disorder (Solomon and
Davidson, 1997)
Curriculum - Blaustein
100
PERCENT ENDORSEMENT
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van der Kolk, Pelcovitz, Roth & Mandel, 1994
90
80
Complex PTSD or DESNOS
70
60
50
40
30
PTSD only
20
10
0
0-4
N=75
5-8
N=92
9-13
N=56
14-19
N=62
20-25
N=16
>26
N=27
AGE AT ONSET OF TRAUMA (years)
Margaret E. Blaustein, Ph.D The Trauma Center at JRI, Brookline, MA, USA
International Congress, Child Abuse and Neglect November 8-9, 2012
2
Adverse Childhood Experiences and
Outcome
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Increased presence of childhood adverse experience leads to
increased risk of:
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Depression
Drug addiction
Alcohol use/abuse
Adult sexual assault
Adult domestic violence (perpetrator and victim)
Early onset sexuality and sexual promiscuity
Teen pregnancy and paternity
Suicidality
Obesity
Cigarette use
General health problems
Diagnostic Issues
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PTSD is the single diagnosis currently in the DSM-IV
to capture chronic adaptations to trauma
PTSD is not the most common diagnosis for youth
who have experienced more chronic adversities
Youth (and adults) who have experienced chronic
adversities frequently meet criteria for a range of other
diagnoses, and individuals with PTSD experience
frequent comorbidity
There is currently a proposal for inclusion of
Developmental Trauma Disorder in the DSM-V
ACE Study (Felitti et al., 1998)
Curriculum - Blaustein
Curriculum - Blaustein
Trauma’s Dual Influence on
Development
Think Developmentally:
Trauma, like all experience, shapes
the course of development.
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Prioritization of those domains of skill /
competency / adaptation which help the child
survive their environment and meet physical, emotional,
and relational needs
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De-emphasis of domains of development which
are less immediately relevant to survival
Curriculum - Blaustein
Curriculum - Blaustein
What helps the child survive?
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Assumption of danger
Competency – Domains of Impact
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Emotional / regulatory capacity
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Ability to understand, tolerate, manage, and share internal
experience
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Rapid mobilization in the face of perceived threat
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Interpersonal abilities
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Self-protective stance
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Intrapersonal development
Development of alternative strategies to meet
developmental needs
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Cognitive development
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Curriculum - Blaustein
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Ability to form and maintain safe relationships
Development of a coherent and positive sense of self
Reflective capacities; ability to understand, make meaning
about, and act on internal and external information in a goaloriented way
Curriculum - Blaustein
Margaret E. Blaustein, Ph.D The Trauma Center at JRI, Brookline, MA, USA
International Congress, Child Abuse and Neglect November 8-9, 2012
3
ARC:
The Attachment, Self-Regulation,
and Competency Framework
A Framework
For
Intervention
with
Complexly
Traumatized
Youth
TRAUMA EXPERIENCE
INTEGRATION
COMPETENCY
REGULATION
ATTACHMENT
•Affect Identification
•Modulation
•Affect Expression
•Caregiver affect management
•Attunement
•Consistent response
•Routines and Rituals
Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005
Preliminary Support:
Compiled data from two sources
Primary Components
•Executive functions
•Self development
Blaustein & Kinniburgh, 2010;
Kinniburgh & Blaustein, 2005
Treatments Utilized in the NCTSN
17.4
TF-CBT
ARC
2.5
1) NCTSN cross-site data
2) Structured 16-week adaptation in
multi-site U.S. implementation
CPP
3.5
PCIT
4.5
SPARCS
8.3
63.8
Other /
Unknown
Total n=966
NCTSN FY 2010 Annual Progress Report – Executive Summary
6-Month Change in CBCL Scores
68
67
66
65
64
63
62
61
60
59
58
57
56
55
54
6-Month Change in UCLA PTSD-RI
Scores
29
27
TF-CBT
ARC
SPARCS
Baseline
3 Months*
6 Months*
NCTSN FY 2010 Annual Progress Report – Executive Summary
*Significant
decreases
on CBCL
scores; no
significant
differences
across
interventions
25
TF-CBT
ARC
23
21
19
17
15
Baseline
3 Months*
6 Months*
NCTSN FY 2010 Annual Progress Report – Executive Summary
Margaret E. Blaustein, Ph.D The Trauma Center at JRI, Brookline, MA, USA
International Congress, Child Abuse and Neglect November 8-9, 2012
*Significant
decreases
on PTSD
scores; no
significant
differences
across
interventions
4
CAPS Total Score
TSC-C
55
54
53
52
51
50
49
48
47
46
45
60
50
40
30
CAPS
Total
Score
20
10
Anxiety
(R2=.14,
p<.001)
0
Pre-Txt
Post-Txt
Outpatient Sample preliminary data; Structured 16-week treatment
N = 481; CAPS Total Score; Pre-treatment CAPS M=58.58, SD=18.54;
2
Post-Treatment CAPS M=38.74,
SD=25.29.
Curriculum
- Blaustein Overall time effect R =.47,
P<.0001
Depression
(R2=.09,
P<.001)
PTS (R2=.12, Dissociation
P<.001)
(R2=.05,
P<.001)
Anger
(R2=.09,
P<.001)
Outpatient Sample preliminary data; Structured 16-week treatment
N=405. Effect size and significance reported for overall time effect across three
time points; Results for Sexual Concerns subscale were not significant.
Curriculum - Blaustein
PSI
40
38
36
34
32
30
28
26
24
22
20
Pre-Txt
Post-Txt
Follow-up
Final Thoughts
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Pre-Txt
Post-Txt
Follow-up
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Parent Parent-Child Perception Perception
Distress - Dysfxn (Mo) of Difficult of Difficult
Mother (R2 = (R2=.04, Child - (Mo.) Child - (Fa.)
.02, p<.05)
P<.001)
- R2=.15,
(R2=.08,
P<.001)
p<.05)
N=383 (Mother report): N=172 (Father report). Effect size and significance reported for
overall time effect across three time points; Change on Parent Distress and Parent-Child
Curriculum - Blaustein
Dysfunction for fathers were not significant.
Trauma is complex and multi-faceted; trauma-related outcomes
are complex and multi-dimensional, and need to be understood
in a developmental context
Children live in multiple embedded systems: the family, the
community, and the larger culture; treatment needs to be
adaptable to and target the needs of the range of “worlds” in
which the child lives
Integration of traumatic experiences incorporates numerous key
intervention targets that include but go beyond narrative, and
include supporting healthy attachment and environment;
building child / adolescent regulatory capacity; and building key
developmental competencies that allow children to actively
engage in their worlds
Curriculum - Blaustein
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For more information about ARC, or to provide feedback or
suggestions, please contact one of the primary authors:
Children are not simply a composite of their
deficits, but are whole beings, with strengths,
vulnerabilities, challenges, and resources.
Margaret E. Blaustein, Ph.D.
Kristine M. Kinniburgh, LICSW
ARC provides a framework that seeks to
recognize factors that derail normative
development, and to work with children,
families, and systems to build or re-build
healthy developmental pathways.
The Trauma Center at JRI
1269 Beacon Street
Brookline, MA 02446
USA
(617) 232-1303
www.traumacenter.org
[email protected]
[email protected]
Blaustein & Kinniburgh, 2009; Kinniburgh & Blaustein, 2005
Blaustein & Kinniburgh, 2010; Kinniburgh & Blaustein, 2005
Margaret E. Blaustein, Ph.D The Trauma Center at JRI, Brookline, MA, USA
International Congress, Child Abuse and Neglect November 8-9, 2012
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